Tuberculosis or Nontuberculosis? A Case of Mycobacterial Skin Infection.

Bacteria other than Mycobacterium tuberculosis and Mycobacterium leprae are known as nontuberculous mycobacteria (NTM), and the frequency of clinically symptomatic forms is increasing day by day. Mycobacterium fortuitum, a rapidly reproducing NTM, causes various clinical signs such as skin soft-tissue infection, surgical site infection, and disseminated infection in immunosuppressed patients. Although progress can be made in terms of diagnosis when growth is detected in culture, it is quite difficult to distinguish between infection and contamination. There is no place for antituberculosis treatment in the treatment of M. fortuitum. Antibiotics such as quinolones, trimethoprim-sulfamethoxazole, linezolid, doxycycline, clarithromycin, azithromycin, imipenem, tigecycline, linezolid, and amikacin are recommended at least in dual combination therapy. In this case presentation, the diagnosis and treatment of a 2-year skin soft-tissue infection with M. fortuitum growth in culture will be discussed.

Dermoscopy and In Vivo Confocal Microscopy Findings of Basal Cell Carcinomas in Xeroderma Pigmentosum Patients.

Background: Xeroderma pigmentosum (XP) is a rare inherited disorder with a high incidence of malignant tumours. Literature data on dermoscopic and in vivo reflectance confocal microscopy (RCM) findings in patients with XP are very limited. Methods: Dermoscopic findings in 32 biopsy-proven BCCs and RCM findings in 10 biopsy-proven BCCs developed in seven XP patients were reviewed. Results: Of 32 BCCs, 28 were pigmented. On dermoscopy, BCCs exhibited multiple grey-blue globules/dots (81, 3%), short-fine telangiectasias/fine arborising vessels (65, 6%), multiple grey-blue ovoid nests (53, 1%), white structures (white-red structureless areas/shiny white areas/lines/strands) (56, 3%), arborising vessels (37, 5%), brown nests/globules/dots (28, 1%), spoke-wheel structures (9, 4%), leaf-like areas (9, 4%), ulceration (28, 1%), peripheral network (21, 9%), and multiple aggregated yellow-white globules (3, 1%). In 10 lesions in which further imaging with RCM was performed, RCM findings differentiated BCC from other tumours, including primary melanoma. Conclusions: Although the dominancy of pigmented structures may imitate melanoma clinically, dermoscopy is a valuable tool in the early diagnosis of BCCs in patients with XP. For suspicious lesions, RCM can help in differentiating pigmented BCC from primary melanoma.

A facial lentiginous nevus with atypical clinical features in a child: The importance of in vivo reflectance confocal microscopic findings.

A 14-year-old girl presented with a facial-pigmented lesion suspicious of melanoma clinically and dermoscopically. In vivo, reflectance confocal microscopy (RCM) findings excluded melanoma by revealing typical epidermal honeycomb and cobblestone patterns. Well-defined follicular contours were seen at the dermal-epidermal junction; there were no elongated, "medusa head-like" follicular protrusions or folliculotropism, which are classical findings seen in lentigo maligna. With this report, we aim to demonstrate the significance of utilizing RCM technology in difficult to diagnose lentiginous pigmented lesions.

In vivo reflectance confocal microscopy findings in a case of atypical fibroxanthoma.

Clinical and dermoscopic features of atypical fibroxanthoma (AFX) are mostly non-diagnostic, so other in vivo diagnostic tools may give additional clues for accurate clinical diagnosis, such as in vivo reflectance confocal microscopy (RCM). However, there has been scarce data on RCM features of AFX in the literature, in only clear cell type. Herein we present a case of epithelioid cell predominant type AFX with RCM findings.

Dermoscopy of haemosiderotic/aneurysmal dermatofibroma: A morphological study of 110 cases.

BACKGROUND: Haemosiderotic and aneurysmal dermatofibromas are uncommon and frequently misdiagnosed lesions, which can be considered as different histopathological stages of the same tumour. A dermoscopic diagnosis testing accuracy has not been performed for these tumours to date. OBJECTIVES: To determine the diagnostic significance of dermoscopic structures and patterns associated with haemosiderotic/ aneurysmal dermatofibromas in a large series. METHODS: Dermoscopic images of histopathologically proven cases of 110 haemosiderotic/ aneurysmal dermatofibromas and 501 other tumours were collected. The frequency, sensitivity, specificity, positive predictive value and negative predictive value of the dermoscopic structures and patterns associated with these lesions were calculated. RESULTS: Haemosiderotic/ aneurysmal dermatofibromas are mostly symmetric lesions (86.5%), and a prominent homogeneous area was present in 100% of them. The presence of vascular structures was very common (86.4%), and dotted vessels were predominant (58.2%). Shiny white structures were seen in 85.5% of lesions, while a peripheral delicate pigment network was present in 69.1%. The most significant pattern was the one composed of a prominent homogeneous area and peripheral delicate pigment network, which showed a specificity of 100% with a relatively good sensitivity (69.1%). All the patterns containing a peripheral delicate pigment network showed very good specificities, positive predictive values and negative predictive values. Those patterns without a peripheral delicate pigment network showed the highest sensitivities, but they showed a significant overlap with other tumours, mainly with melanoma. CONCLUSIONS: Dermoscopy is helpful in improving the diagnostic accuracy of haemosiderotic/ aneurysmal dermatofibromas. However, there is a considerable dermoscopic overlap between these tumours and melanoma, specifically when the peripheral delicate pigment network is absent.

The Use of In Vivo Reflectance Confocal Microscopy for the Diagnosis and Classification of Melasma.

In recent years, in vivo reflectance confocal microscopy (RCM) draws attention as a noninvasive method to precisely detect abnormal pigment deposits, providing additional cytological details for the diagnosis, classification, and treatment monitoring of melasma. This article aims to review the RCM findings of melasma and classify melasma with RCM findings.

Reflectance Confocal Microscopy Findings in a Small-Diameter Invasive Melanoma.

The diagnosis of a small-diameter melanoma may be challenging. We report the case of a 57-year-old man with a small pigmented papular lesion (2.5-mm diameter) that was suspicious on dermoscopy. A more confident differential diagnosis between an atypical nevus and a melanoma was necessary for correct management. Reflectance confocal microscopy (RCM) allowed a confident diagnosis in this lesion, which was an invasive melanoma with 0.3-mm Breslow thickness. This case highlights the benefit of RCM to reach a confident diagnosis and correct management of a small-diameter invasive melanoma.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: 11-year Demographic Clinical and Prognostic Characteristics.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute, life-threatening, severe drug reactions. Randomized studies on these diseases are difficult to perform. Aims and Objectives: The purpose of this study was to summarize the demographic and clinical characteristics of patients with SJS and TEN in a tertiary hospital in Turkey. Materials and Methods: We evaluated the records of 33 patients with SJS and TEN who were followed in our clinic or examined between January 2008 and June 2019, retrospectively. Age, sex, time of admission to hospital, causative drug, presence of concomitant disease, skin findings, mucosal involvement, the severity-of-illness score for TEN, the medication used, antibiotic use, transfer to intensive care, development of complications, and death or discharge status were noted. Results: Of the 33 patients, 11 (33.3%) had SJS, 3 (9.1%) had SJS/TEN overlap, and 19 (57.6%) had TEN. The majority (60.6%) of the patients were female. Nineteen (57.6%) patients had one, and 13 (39.4%) had more than one suspected drug exposure in their history. The most commonly suspected drugs were antibiotics. Twelve (36.4%) patients had intensive care unit hospitalization. Ten (30.3%) patients died. Conclusion: The demographic data of our study were consistent with the literature. Similar to the literature, antibiotics were the most common reaction-causing drugs. However, antiepileptic drugs, which were more frequently reported in other studies, were identified as suspicious in only one patient. We believe that our study will contribute to the determination of characteristics of this rare disease with real-life data.

In vivo reflectance confocal microscopic findings in a case of trichofolliculoma

Abstract Trichofolliculoma is a rare follicular hamartoma whose dermoscopic features have been scarcely reported. On the other hand, reflectance confocal microscopy features have not been described yet. In the present study, the authors report reflectance confocal microscopy features in a case of trichofolliculoma as squamous hyperplasia forming irregular finger-like protrusions around the hair follicle and papillomatous hyperplasia of the hair follicle epithelium, which correlated with histopathology. This case suggests that reflectance confocal microscopy may help incorrect in vivo diagnosis of trichofolliculoma in cases difficult to diagnose by morphology and dermoscopy.

Comparison of Actinic Keratosis and Severity Index with Physician Global Assessment and Total Lesion Count and the Ability to Predict Skin Cancer.

INTRODUCTION: Actinic keratosis (AK) is a known indicator for sun damage, and subsequent squamous cell cancer may develop. The actinic keratosis and severity index (AKASI) is a recently developed tool that can evaluate both field cancerization and AK severity. OBJECTIVES: We sought to evaluate if AKASI was a good predictor of cancer in AK patients and to compare AKASI with both the Physician Global Assessment (PGA) and total lesion count (TLC). METHODS: Ninety patients with AK were included in the study. Each patient was examined, and AKs were scored with AKASI, PGA and TLC by 2 dermatologists. The AKASI, PGA and TLC values were compared between patients with skin cancer and patients without skin cancer. RESULTS: Mean AKASI, PGA, and TLC scores were 4.9, 1.7 and 9 respectively. The patients with skin cancer had higher scores of AKASI, PGA and TLC compared to the patients without skin cancer (P = 0.022, P = 0.014, P = 0.005, respectively). AKASI, PGA and TLC were very strongly correlated with each other (P < 0.001). The AKASI threshold value for non-melanoma skin cancer was determined to be 5.1. CONCLUSIONS: AKASI, PGA and TLC may be used in the assessment of the severity of AK in daily practice or studies and may be considered as valuable tools in determining high-risk patients and to choose treatment option. AKASI seems to have an advantage to give a numeric threshold value for skin cancer.

In vivo reflectance confocal microscopic findings in a case of trichofolliculoma.

Trichofolliculoma is a rare follicular hamartoma whose dermoscopic features have been scarcely reported. On the other hand, reflectance confocal microscopy features have not been described yet. In the present study, the authors report reflectance confocal microscopy features in a case of trichofolliculoma as squamous hyperplasia forming irregular finger-like protrusions around the hair follicle and papillomatous hyperplasia of the hair follicle epithelium, which correlated with histopathology. This case suggests that reflectance confocal microscopy may help incorrect in vivo diagnosis of trichofolliculoma in cases difficult to diagnose by morphology and dermoscopy.

The Usefulness of Dermoscopy for the Recognition of Malignant Collision Tumors.

BACKGROUND: Preoperative diagnosis of malignant collision tumors (MCT) is extremely difficult. The value of dermoscopy to improve the correct detection of these tumors has not been previously studied. This study aims to evaluate the diagnostic accuracy of MCT with and without dermoscopy and to describe the dermoscopic features of a large series of MCT. METHODS: Dermoscopic images of 161 MCT were evaluated. Clinical and dermoscopic images of histopathologically proven MCT intermingled with other tumors were randomly presented to clinicians with different levels of experience, blinded to the diagnosis and objective of the study. The clinical and dermoscopic diagnostic accuracies were measured separately. RESULTS: A total of 161 histopathologically proven cases of MCT were collected. The most frequent MCT was basal cell carcinoma-seborrheic keratosis collision tumor (CT; 37.9%), followed by basal cell carcinoma-melanocytic nevus CT (19.9%), and melanoma-seborrheic keratosis CT (6.8%). Diagnostic accuracy among experts on dermoscopy was 71.4%. The study included 119 participants. The percentage of correct diagnoses was 8% by naked eye examination and 36.4% by dermoscopy (p < 0.001). The presence of the malignant component in the cases of MCT was not recognizable in 19.1% of cases by naked eye examination and in 11.8% of cases by dermoscopy (p < 0.001). CONCLUSIONS: The diagnosis of MCT can be assisted and clarified by dermoscopy. However, many of these lesions manifest complex morphologies and continue to be challenging, even for experts on dermoscopy. Atypical, uncertain, or non-classifiable lesions still need a complete excision for the final diagnosis.

In vivo reflectance confocal microscopic imaging of Leishmania amastigotes (Leishman bodies): A case report.

Cutaneous leishmaniasis (CL) is an intracellular parasitic infectious skin disease with a chronic self-limited course. In vivo reflectance confocal microscopy (RCM) findings in CL have been described in only two cases of CL. We report another case with RCM findings; however to our knowledge, this is the first demonstration of Leishmania amastigotes in RCM imaging. A centrally eroded reddish nodular lesion with a diameter of 12 mm was observed on the leg of a 36-years-old male with a 1-month history. On dermoscopy, a central yellowish crust, and irregularly distributed whitish opaque structures ranging in size and shape (round to polygonal) were observed. There were also irregular vessels mostly at the center and dotted/glomerular vessels at the periphery. On RCM, mild epidermal disarray with some scattered bright cells at the basal layer was observed. At the dermis, dense infiltration of polymorphic/roundish cells with heterogeneous reflectivity was seen. These large, mildly reflecting cells with fine granular structures in their cytoplasm were compatible with macrophages. Histopathology was concordant with CL. The Leishmania amastigotes seen as cytoplasmic granularity on RCM were the clue feature for the initial diagnosis.

A case of lymphangioma circumscriptum with new reflectance confocal microscopy findings.

In vivo reflectance confocal microscopy (RCM) findings of lymphangiomas have been scarcely reported. We report a lymphangioma circumscriptum (LC) with some new observations.

Nivolumab-induced plaque morphea in a malign melanoma patient.

BACKGROUND: Nivolumab is one of the targeted cancer therapy agent that acts to increase the immune responses by inhibition of antiprogrammed-death-receptor 1, which is one of the check points of the immune response. Nivolumab can be used to treat malign melanoma, lung, renal, head and neck, colorectal, hepatocellular cancers, and special cases of Hodgkin lymphoma. AIMS: We aimed to report a rarer cutaneous side effect of nivolumab because of the increasing uses of this agent in various cancer treatments. METHODS: We present a 48-year-old female, metastatic melanoma patient who developed plaque morphea lesion without any systemic involvement during nivolumab treatment. Plaque lesion responded well to use of topical corticosteroid and calcipotriol. RESULTS: Numerous cutaneous side effects associated with nivolumab have been reported in the literature. The most common cutaneous side effects are maculopapular rash, pruritus, and vitiligo. Morphea and disorders from this spectrum reported due to PD-1 inhibitors in the literature are; morphea, sclerodermoid changes, eosinophilic fasciitis, and lichen sclerosis. CONCLUSION: Patients who are treated by PD-1 inhibitors may be examined carefully in terms of morphea and scleroderma-like conditions although they are not as common as other cutaneous side effects.